Tropical Health Matters

Karen E. Kirk, a MSPH-Internal Health Candidate at the Johns Hopkins Bloomberg School of Public Health has written this guest posting based on a poster she presented at the School’s Global Health Day earlier this month.

The inability to eliminate malaria in low endemic settings due to importation by infected individuals is considered a potential barrier in the fight to eradicate malaria worldwide.  Individuals living in the rural Choma District, Southern Province, Zambia have seen a dramatic decline in malaria since 2007 with the implementation of malaria control programs that include active case detection; mass distribution of insecticidal treated nets (ITNs); and widespread use of indoor residual spraying (IRS).  However, malaria elimination has still not been achieved in this region of the country.

The first photo shows field staff collecting blood samples from household members to test for malaria parasitemia in Choma District

A household survey was conducted in the Choma District to assess human population movement (HPM) and its association with confirmed or suspected malaria cases of individuals living in the district. The survey looked at travel history of 196 individuals from 42 randomly selected households between December 2012 and March 2013.  It collected data on travel patterns of individuals from the previous 4 weeks who stayed overnight for at least one night outside of their village. In addition, it collected blood sample for the testing of malaria parasitemia.  This survey was included in both the longitudinal and cross-sectional household surveys being conducted by the International Centers of Excellence in Malaria Research (ICEMR).

The second photo shows Field staff conducting malaria community health and HPM survey with mother in Choma District

Of the 196 individuals surveyed there were 97 (49.5%) adults (ages >17), and 99 (51.5%) children (<17).  There were a total of 34 trips taken by 31 (15.8%) individuals, 18 adults and 13 children. The majority of these individuals (59.3%) traveled for 7 days or less and 27 (87.1%) individuals traveled within the Choma District.  No malaria cases were detected in this study and therefore the results of this preliminary data were not able to show an association between HPM and malaria incidence rates.  However, with an increase in data collected over time, trends could be ascertained to determine seasonal patterns with HPM and its impact on malaria incidence rates in this hypoendemic setting.  The hope is that with adequate funding in malaria research with HPM, these types of studies can contribute important information on malaria transmission and help achieve the goal of regional elimination and ultimately eradication of this harmful disease.

[Bill Moss of JHSPH served as Principal Investor of this project]

The APHA schedule search turned up 31 presentations, panels and posters related to malaria. If you are attending the American Public Health Assocation 140th annual meeting, take advantage of these.

1.    Barriers to practicing healthy behaviors for malaria prevention and child nutrition in Zambia: A qualitative study 263984 Barriers to practicing healthy behaviors for malaria prevention and child nutrition in Zambia: A qualitative study Wednesday, October 31, 2012 Lovemore Mwanza , Research, Monitoring, and Evaluation …

2.    Prevalence of Malaria in Pregnancy as Rwanda Moves towards Malaria Elimination
265783 Prevalence of Malaria in Pregnancy as Rwanda Moves towards Malaria Elimination Tuesday, October 30, 2012 : 3:00 PM – 3:15 PM Corine Karema …

3.    Malaria diagnosis: Perspectives from caregivers and health staff, Makarfi, Nigeria 261566 Malaria diagnosis: Perspectives from caregivers and health staff, Makarfi, Nigeria Tuesday, October 30, 2012 : 8:35 AM – 8:50 AM Olufemi …

4.    Impact of climate and land use influencing the spatial and temporal distribution of malaria risk in the Amazon 261531 Impact of climate and land use influencing the spatial and temporal distribution of malaria risk in the Amazon Tuesday, October 30, 2012 Beth J. Feingold, PhD, MESc, MPH , Department of Earth and Planetary …

5.    Measuring Malaria Advocacy Outcomes 270759 Measuring MalariaAdvocacy Outcomes Monday, October 29, 2012 : 11:30 AM – 11:45 AM Marc Boulay, PhD , Center for Communication Programs, …

6.    How can we Accelerate Programming for Malaria in Pregnancy? 274603 How can we Accelerate Programming for Malaria in Pregnancy? Monday, October 29, 2012 : 11:30 AM – 11:50 AM William R. Brieger, MPH, CHES, DrPH , Jhpiego, …

7.    Improper maternity wear, mean providers, and vomiting: Barriers to timely IPTp uptake for malaria prevention during pregnancy in rural Zambia 266032 Improper maternity wear, mean providers, and vomiting: Barriers to timely IPTp uptake for malaria prevention during pregnancy in rural Zambia Tuesday, October 30, 2012 : 3:15 PM – 3:30 PM Hilary Schwandt, PhD, MHS …

8.    How local government health workers in Nigeria manage suspected malaria cases 265691 How local government health workers in Nigeria manage suspected malaria cases Tuesday, October 30, 2012 : 2:45 PM – 3:00 PM Bright Orji, MPH , Nigeria, Jhpiego, Baltimore, MD William …

9.    Challenges of implementing intermittent preventive treatment in Zambia for malaria prevention in pregnancy 263075 Challenges of implementing intermittent preventive treatment in Zambia for malaria prevention in pregnancy Tuesday, October 30, 2012 : 2:30 PM – 2:45 PM Peter Mumba, MD, MSc , Zambia Integrated …

10.    Contemporary Issues in Malaria in Pregnancy: Why worry now? 274600 Contemporary Issues in Malaria in Pregnancy: Why worry now? Monday, October 29, 2012 : 10:30 AM – 10:50 AM Mary Nell Wegner, EdM, MPH …

11.    Community-based Interventions for Malaria in Pregnancy: Findings from Mozambique 274602 Community-based Interventions forMalaria in Pregnancy: Findings from Mozambique Monday, October 29, 2012 : 11:10 AM – 11:30 AM Leonardo Chavane, MD, MPH , …

12.    Spatial access to malaria treatment in Kenya and its impact on health seeking behavior: A GIS based study 270764 Spatial access to malaria treatment in Kenya and its impact on health seeking behavior: A GIS based study Monday, October 29, 2012 Brittany Goettsch, …

13.    Challenges of Addressing Malaria in Pregnancy through Antenatal Care Services: A Nigerian perspective 274601 Challenges of Addressing Malaria in Pregnancy through Antenatal Care Services: A Nigerian perspective Monday, October 29, 2012 : 10:50 AM – 11:10 AM Oladosu …

14.    Invited Panel: Malaria in Pregnancy: An urgent yet solvable problem uniting the maternal health and malaria communities in Africa 3150.0 Invited Panel: Malaria in Pregnancy: An urgent yet solvable problem uniting the maternal health andmalaria communities in Africa Monday, October 29, 2012: …

15.    Malaria & Vector-Borne Diseases 4320.0 Malaria & Vector-Borne Diseases Tuesday, October 30, 2012: 2:30 PM – 4:00 PM Oral Moderator: Pablo Aguilar, MD MHSc 2:30pm Challenges of implementing …

16.    Poster Session: Nutrition … 2012: 8:30 AM – 9:30 AM Poster Organizer: Mike S. Bailey, MA / Co-Chair Board 1 Barriers to practicing healthy behaviors for malaria prevention and child nutrition in Zambia: A qualitative study Lovemore Mwanza, Rikki Welch, MA, John Manda, Samantha Herrera, Ana Claudia …

17.    *Poster Session*: Emerging issues in environmental public health … MCP and Devon Payne-Sturges, DrPH Board 4 Impact of climate and land use influencing the spatial and temporal distribution of malaria risk in the Amazon Beth J. Feingold, PhD, MESc, MPH, Benjamin Zaitchik, PhD, Victoria Shelus, BSc and William Kuang-Yao Pan, …

18.    Innovation in Technology: Public Health Models Posters 2 … practices serving underserved communities Kristina Vasileva, MPH, Mandy Smith Ryan, PhD and Mariceli Comellas, MA Board 10 Spatial access to malaria treatment in Kenya and its impact on health seeking behavior: A GIS based study Brittany Goettsch, MPH Candiate See individual …

19.    Infectious Disease Epidemiology 2 … AM – 10:00 AM Oral This session will provide new findings in the area of infectious disease epidemiology including the areas of malaria, TB, and influenza. Session Objectives: Assess the adequacy of zip code tabulation areas as a proxy for census tracts when …

20.    Advocacy & Global Health … Kovach, MPH, A. Elisabeth Sommerfelt, MD, MS, Alice Nkoroi, MS, Robert Mwadime, PhD and Ferdousi Begum, MBBS, MS 11:30am Measuring Malaria Advocacy Outcomes Marc Boulay, PhD, Claudia Vondrasek, MPH, Matt Lynch, PhD and Sarah Dalglish, MPH See individual abstracts for presenting …

21.    Seeing the obscured: A social epidemiological assessment of malaria’s reemergence in deforested regions 269174 Seeing the obscured: A social epidemiological assessment of malaria’s reemergence in deforested regions Tuesday, October 30, 2012 Beth Phillips, MPH , Mel and Enid Zuckerman College of Public Health, …

22.    Factors associated with completion of Intermittent Preventative Therapy (IPT) among pregnant women in Malawi … Sciences for Health, Arlington, VA Allison Zakaliya , Baylor Children’s Foundation, Baylor Children’s Foundation, Lilongwe, Malawi Misheck Luhanga , National Malaria Control Program, Ministry of Health, Lilongwe, Malawi Johnes Moyenda , Mpemba Health center, Ministry of Health, Blantyre, Malawi Doreen Ali…

23.    Designing a translational epidemiologic study: Chloroquine and breast cancer chemoprevention in Returned Peace Corps Volunteers … present the design of a novel translational epidemiologic approach to confirm preclinical data on the chemopreventive potential of a well-characterized anti-malarial drug. BACKGROUND: Exposure to chloroquine, an off-patent anti-malarial drug with a 60-year history of use by millions, reduces the incidence…

24.    Exploratory assessment of alternative use of bed nets within the Arisi zone in Ethiopia: Findings from household interviews and observations … Thaddeus Pennas, MS , C-Change, FHI360, Washington, DC Background: Distribution of long lasting insecticide-treated nets (LLINs) is one of four malariaprevention interventions being scaled up in sub-Saharan Africa. Correct and consistent use of LLINs by households is central to the …

25.    Young and vulnerable: Comparing delivery care, domestic violence, and child undernutrition between adolescent girls and women in Bangladesh … and Asia on topics related to evidence-based advocacy to improve nutrition, reduce maternal mortality, increase newborn survival, and decrease the malariaburden; written on child health and nutrition; and domestic violence against women. Carried out the data assessment and analyses. Have …

26.    Determinants of insecticide treated bednet (ITN) use by households in Nigeria … tying ITN to nails on the wall, and frequent washing of the ITN. The number of times a child had malaria in past 6 months, where child slept at night, and use of other malaria control measures were also associated with …

27.    Measuring the competencies and skills of midwives in an accelerated training program in Zambia … 25% felt they were not competent to treat patients with pneumonia while only 2% felt incompetent to manage patients with malaria; neither were statistically associated with duration of service (X2=61539;2=3.163, p=0.075; X2=61539;2=0.002, p=0.962 respectively). Conclusions: The assessment showed that the certified …

28.    Community Health Workers and Prevention: How to measure effectiveness of preventive community health programs centered on CHW … effectiveness of their preventive messages and adapt them for maximum results. With an effective tool to measure the effectiveness of malaria and HIV prevention and messages on hand washing and adequate nutrition, CHW receive immediate feedback on the challenges their communities …

29.    Improving access to preventive healthcare in Haiti: A community based approach … under five years of age, prevention messages delivered through skits, micronutrient supplementation, mosquito nets to pregnant women to help preventMalaria in Pregnancy, and blood pressure checks for all. Preliminary data have shown increased uptake of services and better maternal and …

30.    Mobile technology-based approach for facilitating health data collection, sharing, analysis and use in Uganda … of health centers through UHIN including monthly HMIS reports, disease surveillance data, and specific reports related to HIV/AIDS, TB, and malaria. Rural hospitals use UHIN for capturing data on electronic daily registers such as PMTCT, in-patient, lab, HIV counseling, and ART …

31.    Climate change and blood safety … transmission of dengue fever occurred in France in 2010. Other infectious agents are of concern such as Hanta virus, leishmaniasis, malaria, tick-borne encephalitis and their relationship to climate change and blood safety will be discussed. These insights call for changes in …

The World Bank has announced a project in Nigeria to map the location of high risk populations in order to target interventions more effectively. According to the Bank, “In Nigeria, populations at greatest risk for HIV comprise 3.4% of population but account for up to 40% of new infections.” We hope that such efforts will help decrease disease and not increase stigma and discrimination. But clearly, mapping is an important tool to understand a health problem.

Mapping on the broadest sense has been undertaken for malaria.  An earlier incarnation of African mapping was MARA, which was founded on the idea that mapping could help target resources.  More recently the Malaria Atlas Project (MAP) has tried to refine the mapping process drawing on a wide variety of epidemiological studies in endemic countries. MAP has moved beyond Africa and looks at both P. falciparum  and  P. vivax.

Detailed country maps from MARA and MAP on a country by country basis help us see different transmission and seasonal patterns of disease.  From this we can target regions in a country that may benefit more from indoor residual spraying or intermittent preventive treatment.

The interesting thing about malaria is that transmission can vary even on a micro level.  Urban malaria is a case in point, where there are fewer anopheles mosquito breeding sites in densely populated urban slums, and more in areas where people have gardens.

Even in rural areas transmission can vary by proximity to the watery breeding sources of mosquitoes. Factors ranging from deforestation to rice farming play a localized role in transmission mapping. This should lead to spatial targeting of interventions.

We need to carry mapping and thereby appropriate interventions to the community level to have the greatest effect. At present we are of lucky to get any supplies of malaria commodities into a country and distributed to the next administrative level.  Micro mapping and planning may sound like a dream in this context, but if we are to succeed in eliminating the disease, we may need to carry the fight from one neighborhood, hamlet or block to the next.  Such surveillance is the key to a malaria free future.

Recent research has stressed the increase risk of death from malaria that elderly tourists face. Mortality from P. falciparum malaria increased steadily with increasing age with case fatality rate peaking in the group aged over 65 years. The authors explain that, “These data are supported by previous reports of increased case fatality and higher levels of parasitaemia in elderly people,” but the three studies cited focus only on travelers and tourists back in the UK, not adults and elderly people living in endemic regions.

This leads on to wonder about the risks malaria poses to elderly people in endemic countries, especially as populations throughout the world are aging.

While the recent controversial study that suggests that malaria deaths in adults have been underestimated world-wide, it does not specifically address the suspected prevalence of malaria morbidity and mortality in older adults. Specifically the authors “estimated more deaths in individuals aged 5 years or older than has been estimated in previous studies: 435 000 (307 000-658 000) deaths in Africa and 89 000 (33 000-177 000) deaths outside of Africa in 2010.”

Concerning the “outside Africa” component mentioned above, a study of adult and child malaria mortality (both falciparum and vivax) in India published in 2010 did report a higher malaria mortality risk in persons over 60 years of age.

More documentation on malaria morbidity and mortality in persons over 60 years in age in endemic countries is needed. Although portions of this segment of the population may no longer be in their productive years, they do consume health care resources, and as grandparents play important roles in child care.

In addition there is need to ascertain reasons for any differing patterns that may be detected. The study on tourists did not think that co-morbidity in elderly patients was responsible but instead implied that older people on holidays may forget to take their prophylaxis.

What differences in health behavior might be found in elderly populations in malaria endemic countries – maybe greater reliance on less efficacious indigenous concoctions? Are there differences in terms of perceptions of severity and seriousness of illness? Are there differences in care access?

The respect and quality of care we give the elderly says a lot about the societies in which we live.

Human activity is leading to deforestation in central Africa and bringing hunters and people in closer contact with our primate cousins and their collection of pathogens.  The Global Viral Forecasting Initiative is carefully studying these contacts between humans and other vertebrates in an effort to identify possible new viral epidemics. In the process they have also made observations about the origins of human malaria and the potential for transmission of primate plasmodium infections to people.

While transmission of malaria species between humans and other primates has been documented in South America and Africa, Southeast Asia has received the most attention.  In fact, the question is being raised as to whether P. knowlesi is becoming the fifth human malaria parasite. If new infections as well as new species are arising from the primate world, this has grave implications for efforts to eliminate malaria worldwide.

A recent study from Vietnam found that, “showed P. knowlesi infections in 32 (26%) persons with malaria (n = 125) and in 31 (43%) sporozoite-positive An. dirus mosquitoes (n = 73). The authors observed and warned that …

P. knowlesi–co-infected patients were largely asymptomatic and were concentrated among ethnic minority families who commonly spend nights in the forest. P. knowlesi carriers were significantly younger than those infected with other malaria parasite species. These results imply that even if human malaria could be eliminated, forests that harbor An. dirus mosquitoes and macaque monkeys will remain a reservoir for the zoonotic transmission of P. knowlesi.

In another study researchers confirmed P. knowlesi in humans in Cambodia. This is worrisome especially since Cambodia is one of the locations where resistance to artemisinin-based medicines is rising.

Likewise, researchers in Malaysia reported that, “P. knowlesi is a major cause of severe and fatal malaria in Sabah. Artemisinin derivatives rapidly clear parasitemia and are efficacious in treating uncomplicated and severe knowlesi malaria.”  Gametocytes of P. knowlesi in a Giemsa-stained thin blood smear from a patient that traveled to the Philippines can be seen in the attached photo from CDC.

Simian reservoirs of malaria throughout Southeast Asia pose a major challenge for control efforts.  Tackling this problem in the forest habitats where people come into contact with monkeys will be daunting – we are not out of the woods yet for malaria elimination.

November 11th is Veteran’s Day in the United States. Over the years soldiers have been vulnerable to malaria. During the U.S. Civil War 150 years ago over 14,000 Union troops are estimated to have died from malaria. While death estimates were not available for the Confederates, it was thought that over 40,000 malaria cases occurred in an 18-month period in the middle of the war.

Today places like Afghanistan and the Horn of Africa pose a malaria threat to troops, so there is malaria prophylaxis for soldiers. Sometimes the prevention itself poses problems. “The Army has dropped Lariam — the drug linked to side effects including suicidal tendencies, anxiety, aggression and paranoia,” and now prefers doxycycline for people who may react to mefloquine.

The military takes malaria seriously now. The Walter Reed Army Institute of Research (WRAIR) puts a priority on malaria research since, “Malaria remains highly relevant to the military because of its prevalence, variety (there are four species that infect humans), debilitating nature, potential lethality, and tendency to become resistant to drugs. No organization in the world has WRAIR’s experience in the complete spectrum of malaria research.”

WRAIR’s “Work on a vaccine is also progressing. Advanced molecular, genetic, and biomedical technologies are now being employed to produce candidate malaria vaccines. Field trials of these candidate pharmaceuticals are an essential part of the program and are underway in Thailand and Kenya.”

The military of all nations are at risk when they serve in malaria endemic areas. For example, a Philippine soldier “succumbed to malaria on 23 October 2008 while serving as a military observer with the U.N. Mission in Sudan.”

Another concern of malaria in the military is the potential for soldiers who contract malaria for spreading it to other countries or bringing it home. It was reported that Soviet soldiers serving in Afghanistan some years ago brought the disease back to republics in the Caucasus and Central Asia. Though this particular spread could be controlled, not all situations may be so fortunate.

Today a variety of injury and mental health problems may overwhelm the effects of malaria on soldiers. Still, soldiers are at risk. For example in 2002, “38 cases of malaria were identifiedin a 725-man Ranger Task Force that deployed to eastern Afghanistan.” Also over a 6-year span the Defense Medical Surveillance System reported 423 cases of malaria including Plasmodium vivax, P. falciparum, P. ovale, and P. malaria. A big challenge is the inability of health systems in non-endemic countries to treat and save lives of soldiers who return home with the disease.

There are basically two lessons from this issue. First malaria control must recognize that soldiers who may not be immune when they enter a malaria endemic war zone are at risk of malaria death. Secondly, as a mobile population soldiers have the potential for reintroducing malaria to areas where it may have been eliminated. War kills people; malaria kills people – when soldiers are infected a double dose of death potentially occurs

Humans and monkeys have shared and competed in the same environments, though not always to the benefit of monkeys.  In an interesting form of retribution for killing and eating monkeys, humans may have acquired the simian immunodeficiency virus (SIV) which mutated into HIV.

Although the earliest evidence of HIV was traced to about 60 years ago, a new study in Science as reported by the New York Times, suggests that monkeys may have harbored SIV for over 30,000 years. The Times notes that scientists have questioned …

What happened in Africa in the early 20th century that let a mild monkey disease move into humans, mutate to become highly transmissible and then explode into one of history’s great killers, one that has claimed 25 million lives so far? Among the theories different researchers have put forward are the growth of African cities and the proliferation of cheap syringes.

HIV is not the only health problem humans and monkeys share. Erma Sulistyaningsih and colleagues are among the most recent to address the problem of Plasmodium knowlesi, acquired from monkeys when tourists among others visit forests as a possible fifth form of human malaria in southeastern Asia including Indonesia, Malaysia, Vietnam,  the Philippines and recently in Myanmar.

There is also … “the theory of P. vivax originating in macaques in Southeast Asia and the close relationship to other primate malaria parasites.” Studies in Brazil also show that monkeys could serve as reservoirs for P vivax.

Researchers have also been exploring the “co-speciation hypothesis” in the relationship between P. reichenowi in chimpanzees and P. falciparum in humans. Hughes and Verra concluded that, “The available data are thus most consistent with the hypothesis that P. reichenowi (in the strict sense) and P. falciparum co-speciated with their hosts about 5–7 million years ago.”

Then last year Medical News Today reported that, “Researchers based in Gabon and France report the discovery of a new malaria agent infecting chimpanzees in Central Africa. This new species, named Plasmodium gaboni, is a close relative of the most virulent human agent P. falciparum.”

The authors of the Gabon study warn that, “The risk of transfer and emergence of this new species in humans must be now seriously considered given that it was found in two chimpanzees living in contact with humans and its close relatedness to the most virulent agent of malaria.” Similarly other researchers have expressed concern that, “Finally, our data and that of others indicated that chimpanzees and bonobos maintain malaria parasites, to which humans are susceptible, a factor of some relevance to the renewed efforts to eradicate malaria.”

Hence we see the lesson. In all our efforts to eliminate malaria, we do not want to monkey around with other possible reservoirs of infection.  Capacity to monitor our simian cousins is a key element in eventually ridding humans of the malaria parasite.

In many parts of the tropical world malaria is seasonal, depending in large part upon rains.  If taken into account, seasonality can allow malaria program managers to plan better to serve different areas of their countries.  There are areas where a dry season or colder weather may appear to put a stop to transmission completely, but often minimal transmission manages to take place.

When we know that some areas have more intense malaria transmission during certain times of year, we can ensure that our interventions are in place well in advance of major rains.  Knowledge of seasonality can guide vector control efforts and help plan for increased stocks of medicines and diagnostic tests in clinics, for example.  Several examples of the need for such preparations have been in the news this weekend.

Malaria’s Day in Court

In India the Kolkata Municipal Corporation is apparently under legal investigation for inadequate supplies of malaria medicines in clinics in Bhowanipore, which is a malaria-prone area.  In a bid to find out what he needed to do, a medical officer unknowingly broke protocol and visited the judge hearing the case to get advice on how better to serve the people of the area.

Fortunately he was not reprimanded for his efforts to get ahead of impending malaria outbreaks.

Awaiting the Storm

Adding to Haiti’s existing medical chaos and suffering is the season of increasing rains.  People are still living in makeshift tents that given no protection when it comes to mosquitoes and malaria.

The Boston Globe reports that, “Some rain typically falls every month in Haiti, meteorologists say, but heavy downpours could begin as early as this month.”  As seen in the satellite photo from NOAA, Haiti was in the path of several major hurricanes and tropical storms in 2008 – so rains from these storms kill people directly through flooding, and those who survive can expect to be threatened with malaria.

Interfaith Preparation

Nigeria accounts for at least one-fourth of the malaria deaths in Africa, according to AFP.  A major national net distribution is underway, which will hopefully make major inroads before the heavy rains start.

Planning is the key – we must understand the malaria transmission patterns in our countries and plan to get the material and human resources in place in a timely manner so that they will be effective in bringing down malaria morbidity and mortality.

Women and men have different health and disease experiences according to an article this morning in the Baltimore Sun. The article stresses that, “A rapidly growing body of research shows men and women are biologically different in ways that have nothing to do with the obvious physical features and lots to do with which diseases strike and how successfully or not the body fights them off.”

Some of the highlighted examples include …

• Women’s bodies have been shown to generate a stronger antibody response to the H1N1 vaccine than men’s
• Autism is four times more common in males
• Lupus and irritable bowel syndrome predominantly afflict females

The Sun article states that like many innovative thoughts and practices, “… for the most part, the idea that males and females are very different patients hasn’t made its way into the doctor’s office.” Fortunately the Society for Women’s Health Research is trying to address these issues.

We might ask, is there evidence that malaria affects men and women differently? Such differences may be biological – sex-related; while other differences may be social – gender-related.

Among travelers, Schlagenhauf and colleagues found that, “Women are proportionately less likely to have febrile illnesses (OR, 0.15; 95% CI, 0.10-0.21) [and] vector-borne diseases, such as malaria (OR, 0.46; 95% CI, 0.41-0.51).”  Munga and Gideon learned that a greater proportion of women in rural Tanzania reported malaria episodes compared to men, while the opposite was true in urban areas. They surmise that social or gender roles may actually increase the exposure to mosquitoes in each setting.

In Yemen El-Taiar and colleagues observed that women were less likely to associate malaria with mosquitoes and that “different beliefs and roles identified between men and women need to be taken into account in health promotion messages.” In many places women have less access to formal education than men.

“Some research suggests that gender may influence the use of ITNs within households, as different roles dictate different sleeping patterns for men and women,” as Toe and colleagues summarized from the literature. Ahmed et al. in Bangladesh observed a “gender divide in knowledge and health-seeking behaviour was observed disfavouring women,” with malaria-like symptoms.

Other studies have shown that pregnant women attract more malaria-bearing mosquitoes, a biological issue in Sudan and The Gambia. Intra-household gender issues have been found to influence equitable use of bednets.

We welcome readers to contribute other examples of the gender and human biological factors that may influence malaria and its control. The key lesson is that unless we plan for both sets of influences, our tools may not be fully effective or equitably utilized in order to achieve universal coverage and mortality reduction.

Thirty-four centuries ago, when preparing the body of the 20-year old Egyptian king for the afterlife, the embalmers probably could not imagine the later worldwide interest and curiosity in this young royal – a life after death that has been in the spotlight since 1922. Much speculation and research has centered King Tutankhamun’s death.

Archaeology Magazine reports that, “new evidence of Tutankhamun’s reign has emerged that shows he was much more active than was thought, and may have led military campaigns against the Syrians and Nubians before he died,” as exemplified to the left where Archaeology Magazine shows Tutankhamun as a sphinx, trampling Egypt’s traditional foes, a Syrian or Asiatic and a Nubian (picture by Araldo De Luca).

“The recent reexamination of Tutankhamun’s body suggests that his death was the result of an accident that injured his leg, leading to a fatal infection.” Coinciding with this report is publication of medical evidence that King Tut’s death may have been more complicated.

The Journal of the American Medical Association reports that for the past two years “royal mummies underwent detailed anthropological, radiological, and genetic studies as part of the King Tutankhamun Family Project.” Hawass and colleagues found that …

These results suggest avascular bone necrosis in conjunction with the malarial infection as the most likely cause of death in Tutankhamun. Walking impairment and malarial disease sustained by Tutankhamun is supported by the discovery of canes and an afterlife pharmacy in his tomb.

The researchers discovered “genes specific for Plasmodium falciparum” in several of the mummies. Over 3,000 years later, Egypt is almost free from malaria. Dahesh and colleagues discuss that, “remnant residual foci are still localized in two districts; Sinnuris and Faiyoum, Faiyoum Governorate.”

The herbal apothecary found in King Tut’s tomb also suggest treatment for malaria. Whether malaria itself was the ultimate cause of demise has been questioned. Mark Rose of Archaeology.org says, “I suspect that they are overdoing it a bit” when researchers portray the king as a weakling who was finally knocked out by malaria. We need to know more about malaria transmission and ecology in the area many years ago to give a better conclusion.

If the king’s domain was in an area of stable transmission, it would be unusual for an adult to succumb to malaria, having developed some immunity over the years.  Had the area been one of seasonal or epidemic malaria, a bout of the disease could have been the final blow.

Transmission may have been seasonal following the annual floods. Bernard Ziskind observes that ancient texts show the Nile valley to be particularly susceptible to malaria. He quoted Herodotus who reported around 430 BC that Egyptians living in marshy areas used nets for fishing by day and protection from mosquitoes by night.

More than three thousand years of malaria transmission is a sobering thought. We have been trying to eradicate it for less that 100 years.  We have more tools to fight the disease than the herbs and fishnets of ancient times, but King Tut’s new diagnosis should remind us that this ancient disease will not go quietly.